I am interested in the average dose of conscious sedation that Endo nurses are giving. We use demerol and versed at my hospital and feel that several of our doctors need more education on conscious... Read More

Feb 22, '04

I am an operating room nurse with over 25 years experience, and I do not feel that OR nurses--or endo nurses--should be giving conscious sedation, and definitely NEVER propofol. All the "training"--inservices, rather--they can give us in the world does not equate to the training any CRNA or anesthesiologist has, particularly in airway management, and the fact is that we are not trained to handle one level deeper than conscious sedation--that is, general anesthesia.

Check out the ongoing thread of mine in the CRNA section entitled "OR Nurses Giving Conscious Sedation--Why Should We?" I would welcome your comments.

Also, if you have no other objections to putting your license on the line, think about it--they just don't pay us enough to do a CRNA's or anesthesiologist's job.

An article follows for your general interest. As usual it, took a patient death to effect change to an ongoing dangerous practice.

FYI on Propofol Administration by RNs

Saying that it has received several reports of adverse events, including
the death of a cosmetic surgery patient, after RNs improperly
administered propofol, the American Association for Accreditation of
Ambulatory Surgery Facilities (AAAASF) is rushing to ensure that only
those trained to give general anesthesia or rescue from general
anesthesia administer propofol in its 1,100 or so accredited facilities.
The AAAASF announced last week that facilities that want to continue to
use propofol -- even if only for "conscious sedation" -- must either
upgrade to a Class C facility (where all anesthesia must be administered
by an anesthesiologist or CRNA) or promise to always use an anesthesia
professional to administer the drug. Facilities must comply by May 1.

"We decided that we need to get our standards in line with the
manufacturer's recommendations," says Jeff Pearcy, executive director of
the AAAASF. "The easiest way to do that was to require those facilities
that want to continue to use propofol to become Class C facilities."

For Class B facilities that would like to continue to use propofol but
won't use other types of general anesthesia, complying with the new
standard is simple. These facilities must fill out a form certifying
that they have a dedicated anesthesiologist or CRNA administering the
sedative-hypnotic. They also must have neuromuscular blocking agents
available in the facility. No on-site inspection is necessary. There
will be no additional charge, says AAAASF.

Those facilities that are upgrading to a C and plan to use general
anesthesia (inhalational) in addition to using propofol must comply with
all Class C criteria, says AAAASF.

AAAASF President Michael F. McGuire, MD, a board-certified plastic
surgeon, says the major motivation for making the change was that
"administration of propofol by a non-anesthesia provider is really not
appropriate."

Dr. McGuire adds that the new standard has caused quite a bit of
confusion and concern, mostly among Class B facilities that don't give
inhalational anesthesia and misread the standard to mean they couldn't
administer propofol unless they bought an anesthesia machine and CO2
monitor. Part of the confusion, he says, lies in the nature of the
propofol.

"Is propofol a general anesthetic or a sedation agent? It's both.
Really, truly, it is both," says Dr. McGuire. "At a certain level and in
a certain individual, it is a sedation agent. In other individuals or at
higher does, it becomes a general anesthetic agent. It's so
unpredictable, which is not a problem if you're an anesthesiologist but
can be if you're a surgeon trying to do surgery and supervise a nurse
giving the medication."
__________________

Feb 25, '04

I'm going with Stevie on this one.

As a RN/NP (ACNP/FNP) I am 100% about showing what nurses can do.
However, giving CS is not one of them, unless you're a NP or CRNA. Some people will even exclude NP from that list.

Some of the doseages listed in this thread are not quite right. They seem very, very light on the sedation, and others a bit heavy handed.

I am sure that every one of you practices the absolute best nursing you can. I would just prefer that this be left to those with a little bit more training.

-Dave, who wears a flame retardant suit... so don't bother

Feb 27, '04

Quote from prmenrs

I had this proceedure done to me yesterday. I haven't had that much pain since I had appendicitis! I was told I got 100 of Demoerol and 5 of versed, but I'm here to tell you IT DIDN'T WORK!! I remember everything, including saying ouch continuously throughout the fun and asking them to stop at least twice.
Can anyone explain why they didn't stop and get the pain under control?
When I asked later why it hurt so much the doc mumbled something about me being "too fat"! (I am fat, but I don't believe that's why it hurt so bad, and if that's really the case, why wasn't I warned ahead of time?)
It's been &gt;24hours, and everytime I think about this, I start crying.
Any insight you can provide would be appreciated. Thanks

I had mine done MOnday (this week) and was totally terrified going in. Totally. It seems I found a wonderful doc, very reassuring, very gentle, and had no pain except a couple cramps. 100 mg demerol, 10 mg versed. I am convinced the doc makes a huge difference. I'd waste no time finding a new one for next time. I'd drive hours to another state if I had to. There's no point in trying to reason with one that doesn't understand or doesn't care. Or is pressured to stick to a time schedule, so he has to move quickly and is rough. Ask around to find out who had a good experience and start there. Word of mouth is a good way to find a decent doc. You will pay enough for the services, you may as well have a good outcome! Take care! Good luck!

Feb 28, '04

bbarbie1:

I am glad to hear that your colonoscopy experience was so tolerable. Can I also infer from the upbeat tone of your posting that no problems were found during the examination?

Mar 30, '04

Quote from mshultz

bbarbie1:

I am glad to hear that your colonoscopy experience was so tolerable. Can I also infer from the upbeat tone of your posting that no problems were found during the examination?

No, there were no problems. I still would not do this on my day off, please don't misunderstand me. And I still don't understand why SCREENING procedures have to be so stress-inducing and invasive of one's person, but hey, it's done. And I'm not doing it again one second before 10 years is up!

I survived!! Thanks for your inquiry. Good health to you.

Apr 1, '04

Quote from prmenrs

I had this proceedure done to me yesterday. I haven't had that much pain since I had appendicitis! I was told I got 100 of Demoerol and 5 of versed, but I'm here to tell you IT DIDN'T WORK!! I remember everything, including saying ouch continuously throughout the fun and asking them to stop at least twice.
Can anyone explain why they didn't stop and get the pain under control?
When I asked later why it hurt so much the doc mumbled something about me being "too fat"! (I am fat, but I don't believe that's why it hurt so bad, and if that's really the case, why wasn't I warned ahead of time?)
It's been &gt;24hours, and everytime I think about this, I start crying.
Any insight you can provide would be appreciated. Thanks

Hi,

I do conscious sedation for an endo lab, have done cardiac E/P requiring 360 J shocks previously and have had little problem with pt.s remembering. Docs need a better understanding of c/s, although lo and behold, a few trust our judgement. It has been my experience that more than a few docs don't know their patient. Example: a terminated ERCP. The patient rushed to RR for code due to VT. I pointed out that the patient had an implated defibrillator that was doing it's job overdrive pacing. The doc didn't know. Another example is a doc who was performing a colonoscopy and couldn't understand the anatomy he was seeing. I advised him that the patient had a history of partial colectomy, and had to read his H&P to convince the GE of the patient's history. He was viewing an anastomosis. These things make the nurse unpopular for pointing them out.

ASA score done correctly are a good index to start, meds regularly taken, and simply asking the patient their experience with painkillers and the like. Let them vent their anxieties, annswer questions, help them to feel at ease. I used to play Tai C'hi music in the background with low lights and soft verbal suggestion, as well as accupuncture point stimulation. It is controversial as to the power of suggestion, I think it works. I have probably put over 2000 people under sedation. That being the case, my gut helps a lot. I use the Ramsay scale and shoot for about a 4. This is an objective scale and has justified my practice on a few occasions.

Some will tell you that if they are on antidepressant/antianxiety drugs they require more painkiller. I have seen nurses just start pushing heavy doses on this class of patient. Wrong! Don't assume anything and start pushing. I usually give a test dose of 1-2 versed without the patient knowing, and observe results as I attend to other duties. Titrate to your desired level carefully and according to policy. I realize that the physician thinks they should be well sedated in 5 minutes or so, which is a violation of policy on most patients. Or they expect that one can just keep pushing drugs after they start the procedure. Getting through the sigmoid with an ill sedated patient is extremely painful, especially if a loop forms. Remember that extreme pain is just as dangerous as oversedation. Read the literature.

I prefer Fentanyl, less side effect, rapid response and recovery, more controllable, less instance of nausea. Why the docs are so hung up on Demerol, I don't know. If you read c/s literature, there is little or no mention of Demerol, fentanyl and MS being the preferred agents. You can't use MS in an endo setting due to the side effect of causing or exacerbating colon spacticity. When you have a patient with an MS implanted pump you have this dual problem of spacticity and delayed reaction where they are difficult to arouse post procedure when everything catches up.

IMHO, practitioners should be familiar with the Ramsay scale and utilize it to achieve optimal sedation without going beyond your constraints of how deep a nurse can take a patient.

There will always be the occasional patient that just won't go down for reasons beyond me, given that they were honest on their history form. So you do the best you can.

I have heard Brevital "brief if used at all" is good for short operative stuff but the solution is not suppose to be used with or come in contact with rubber stoppers or parts of syringes treated with silicone... and that would pose a problem usless your using glass.. good luck finding a glass syringe. Maybe they still use them in Texas.

Apr 5, '04

Quote from TMnurse

I have heard Brevital "brief if used at all" is good for short operative stuff but the solution is not suppose to be used with or come in contact with rubber stoppers or parts of syringes treated with silicone... and that would pose a problem usless your using glass.. good luck finding a glass syringe. Maybe they still use them in Texas.

Ha! Well maybe us poor little cow-pokes might be able to rustle one up. However, I am curious as to why that is not discussed in the prescribing information or any literature that is currently available concerning Brevital. Perhaps you could lead me in the right direction on this.

Apr 5, '04

A GI doc mentionrf that contraidication sometime ago to me. I confirmed it with a Nurses Drug Guide 1998. However, I spoke with one of our MDAs today. He mentioned that those concerns have since been ruled out (also not mentioned on Eli Lillys drug info). He did mention that the drug is asssociated with hiccups... as you know hiccups in a sedated patient are a wonderful combination for aspiration hence, it is not a drug of choice.

Apr 5, '04

Quote from TMnurse

A GI doc mentionrf that contraidication sometime ago to me. I confirmed it with a Nurses Drug Guide 1998. However, I spoke with one of our MDAs today. He mentioned that those concerns have since been ruled out (also not mentioned on Eli Lillys drug info). He did mention that the drug is asssociated with hiccups... as you know hiccups in a sedated patient are a wonderful combination for aspiration hence, it is not a drug of choice.

Perhaps we work in different environments. When I sedate a patient, it is not to the point where their protective reflexes are smashed, because that would be an anesthesia induction. I also have a crash cart and airway kit ready just in case. I ALWAYS premedicate with an antiemetic, and if they come in and JUST ate, I will either order a gastric lavage/NG tube or load them up, give them some Reglan, and wait for a while. But this stuff has such a short duration of action that I like to use it on things like reduction of joint dislocations, etc. They come out of it in just a few minutes and when they begin to emerge, I give them an analgesic for pain.

Aug 4, '04

Quote from prmenrs

Thanks for responding! I am on antidepressants, and my psych told me that could have affected how the drugs were metabolized and how I felt afterward. That helped a lot! Maybe for pts like me who are on more than a couple of meds, a pharmacist should review the profile and advise. I'm going to make that suggestion.
Again, Thank you for your help. It will be a long time before I do this again, even though I realize the importance!

I had a similar problem with an upper GI endoscopy. I am on about 10 oral medications with 2 being antidepressants. My GI doctor told me he gave me a boatload of sedation but couldn't get me out. He is planning on giving me even more with my colonoscopy coming up in September.

I've been told that people who are on antidepressants generally have a higher tolerance and need higher dosages of sedation. Has that been your experience?